JPOSNA® Special Edition
2022 Annual Meeting Pre-Course on Diversity, Equity, and Inclusion


Inclusion and Allyship in Orthopaedic Surgery Training and Practice

Aliya G. Feroe, MD, MPH

Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN

Correspondence: Aliya G. Feroe, MD, MPH, Department of Orthopaedic Surgery, Mayo Clinic, 200 First St. SW, Rochester, MN 55905. E-mail: [email protected]

Received: August 10, 2022; Accepted: August 15, 2022; Published: February 15, 2023

DOI: 10.55275/JPOSNA-2023-558

Volume 5, Number S1, February 2023

Abstract

Over the last several years, there has been an increased focus on diversity, equity, and inclusion in undergraduate and graduate medical education. Creating a culture of inclusion is necessary to recruit and retain diverse healthcare workers and reap the benefits of a diverse workplace. Allyship serves to build such a culture of inclusion by supporting, amplifying, and promoting marginalized voices. The journey towards active allyship requires identifying personal privilege, power, and biases, seeking out education on the broad range of experiences and challenges faced by many individuals from marginalized groups, and empowering these individuals to lead and succeed. Ultimately, a culture of inclusion and allyship will help to optimize the medical training and practice environment for the benefit of patients, colleagues, and trainees alike.

Key Concepts

  • Allyship is at the core of a diverse, equitable, and inclusive healthcare workforce by supporting, amplifying, and promoting marginalized voices.
  • Active allyship requires the exploration of personal privilege, power, and biases, the pursuit of education, and the empowerment of others.
  • A culture of inclusion and allyship will help to optimize the medical training and practice environment for the benefit of patients, colleagues, and trainees alike.

Introduction

Over the last several years, the field of orthopaedic surgery has seen an increased focus on diversity, equity, and inclusion. The American Academy of Orthopaedic Surgeons (AAOS) has asserted diversity, equity, and inclusion work as a key area of focus, committing $1 million to support diversity initiatives.1 However, such discussions tend to focus on the achievement of diversity in the workplace while losing sight of how to truly attract and reattain diversity in practice. This latter, more challenging, goal is accomplished by fostering a culture of inclusivity.

It is important to distinguish between the concepts of diversity and inclusion. Diversity can be defined as the full spectrum of human identities and differences, while inclusion refers to a cultural and environmental feeling of belonging. Many different metaphors have been described over time to conceptualize this distinction. In considering a puzzle, diversity represents the many individual puzzle pieces that represent characteristics such as age, gender identity, race, ethnicity, sexual orientation, disability, and socioeconomic status. Inclusion, in comparison, reflects how all of these pieces connect with each other to unite a cohesive group.2 In considering an athletic team, Joni Davis, Vice President and Chief Diversity Officer for Duke Energy explains, “Diversity speaks to who is on the team, but inclusion focuses on who is really in the game.”3 This metaphor emphasizes the distinct difference in opportunities to lead and succeed, differentially awarded to and achieved by players on the field rather than those traditionally on the sidelines.

In any organization of people (such as a surgical department or a healthcare team), one of the most important elements required to create a culture of inclusion is allyship. While historically associated with support for lesbian, gay, bisexual, transgender, queer, and other sexual and gender minority (LGBTQ+) communities, ally — from the Latin word meaning “to bind together” — is more broadly defined as the use of power and privilege to lift up marginalized groups with which one does not belong.4 A recent article on allyship in the workplace described how, in contrast to established movements (such as Black Coats for White Lives), allyship is fueled by individual efforts: “Allyship is a strategic mechanism used by individuals to become collaborators, accomplices, and co-conspirators who fight in justice and promote equity in the workplace through supportive personal relationships and public acts of sponsorship and advocacy.”5 In medicine, such personal relationships include patients, colleagues, and communities.

Allyship in Medicine and Training

When considering the journey to allyship, reservations are common and questions arise: As a person who identifies as [insert identity group], what does it mean to be an ally for [insert different identity group]? Am I really the right person to serve as an ally if I have never experienced the same difficulties? What if I do or say the wrong thing?

In reality, healthcare professionals are trained specifically to navigate this type of discomfort.6 Throughout their careers, clinicians care for and treat patients who suffer from illnesses that these clinicians have never experienced. There is a universal understanding in healthcare that complications are certain, mistakes are inevitable, and there are times in which medicine falls short of a cure. Yet, through all of these challenges, it is the gift of empathy that is at the core of healthcare — attempting to step into another pair of shoes that may be entirely unfamiliar. Allyship is remarkably similar.

The Allyship Journey

Growing and serving as an ally involves three critical steps: 1) Reflecting upon one’s own circumstances, 2) Lifelong learning and unlearning, and 3) Taking individual actions to support others on the individual and group level.

Self-Reflection

The role that allies can serve depends on their own privilege, power, and knowledge of individual cognitive biases. Privilege considers the set of unearned benefits that belong to people in a certain social group due to any number of characteristics, such as race, gender, language fluency, and physical ability. Privilege subsequently shapes one’s power by defining a person’s access to physical and social capital that helps determine somebody’s experience in the world. Examples may include the power of a doctor on a healthcare team, a department chair, and a residency program director. Reflection upon one’s own power and privilege provides an awareness of the tools that can be leveraged as an ally to empower others.

An understanding of one’s own implicit biases, or subconscious attitudes or stereotypes that affect one’s actions and decisions regarding others, serves to bridge the common disconnect between seeing oneself as an ally versus actively supporting marginalized groups. Racism, for instance, can interact with cognitive biases to influence clinicians’ decisions and subsequently impact patients’ decisions (such as a delay or avoidance of seeking healthcare and lower use of preventive screening).7 As an example, the false belief about biological differences between pain perception by Black patients and white patients has led to known racial disparities in pain management.810 For these reasons, awareness of implicit biases can help healthcare professionals mitigate the potential harm caused by their own subconscious thoughts as well as provide the knowledge to address biased acts committed by others. An excellent resource to explore a person’s own biases related to a variety of identities (such as race, gender, weight, and age) is the Implicit Association Test (IAT), a tool developed by researchers at Harvard University.11

Lifelong Learning

Becoming an orthopaedic surgeon, for instance, requires nearly a decade of schooling and training shaped by constructive feedback and practice, followed by lifelong continuing education. Learning outside of formal educational institutions requires active participation and can be acquired by reading books, attending lectures and webinars, and exploring a broad spectrum of others’ experiences and practices. Allyship requires a similar self-driven dedication to learning. “Self-driven” education is critical to reducing the ‘minority tax,’ a burden that many individuals from marginalized groups carry when they are asked (or pressured) to facilitate identity-related education. This burden can be alleviated by taking an active role to self-educate with many available resources.

Several orthopaedic organizations provide basic education on these topics. Such institutions include, but are not limited to, Black Women Orthopaedic Surgeons (BWOS), Pride Ortho, Nth Dimensions, International Orthopaedic Diversity Alliance (IODA), J. Robert Gladden Orthopaedic Society (JRGOS), and Ruth Jackson Orthopaedic Society (RJOS). Outside of orthopaedic surgery, other valuable resources include the well-supported Allyship in Residency virtual curriculum on MedEdPORTAL12 or Nova Reid’s book, The Good Ally, among others.

Inclusive communication is one particular high-yield avenue for self-education. In a recent analysis of more than 18,000 patients, negative, stigmatizing language such as “resistant” or “non-compliant” was 2.5 times more likely to show up in the medical records of Black patients than white patients, raising concern for discriminatory healthcare practices.13 The use of inclusive language can also serve as a symbol of safety to individuals from marginalized groups, such as using the gender-neutral terms “partner” or “spouse” rather than “husband” or “wife.” Similarly, using the correct pronouns and names to refer to transgender and non-binary individuals lowers rates of depression and suicide and raises self-esteem among these groups.14 Inclusive communication is core to allyship, given the broad impact of just a few words.

Roles of Allies

Allies can serve in a number of roles depending on their privilege and power in a group or organization. Senior faculty members can create a safe space for junior faculty as well as residents and medical students, simply with use of inclusive language. Department chairs can institute unbiased hiring practices. Current residents can recruit future residents that may not come from the ‘traditional’ orthopaedic background. Table 1 summarizes these various roles under one particular framework.15

Table 1. Summary of Karen Catlin’s Seven Roles of Allies in the Workplace

Role Description
Scholar Seeks to learn everything about challenges faced by colleagues from underrepresented groups
 –  From literature, podcasts, peers
Confidant Creates safe spaces for colleagues from underrepresented groups to express fears, frustrations, and needs
 –  Listens, cultivates trust
Sponsor Openly promotes colleagues from underrepresented groups
 –  Highlights strengths, recommends to projects/scholarships/awards
Champion Openly promotes colleagues from underrepresented groups on a public scale
 –  Defers to more expert colleagues from underrepresented groups for panels and in meetings
Advocate Uses power and influence to bring colleagues from underrepresented groups into exclusive circles
 –  Addresses unjust omissions in committees and training programs
Upstander Recognizes wrongdoing and acts to combat it
 –  Addresses microaggressions, speaks up against degrading language
Amplifier Ensures that a wide range of voices are heard
 –  Reiterates and credits others’ ideas

Catlin K, McGraw S: Better Allies: Everyday Actions to Create Inclusive, Engaging Workplaces: Better Allies Press, 2019.15

Summary

Creating a culture of inclusion is necessary to recruit and retain a diverse learning and work environment. Allyship serves to build a culture of inclusion by supporting and promoting marginalized voices. The journey towards active allyship requires identifying personal privilege, power, and biases, seeking out education, and empowering individuals from marginalized groups to lead and succeed. Ultimately, a culture of inclusion and allyship will help to optimize the medical training and practice environment, which benefits patients, colleagues, and trainees alike.

Disclaimer

The author is the Vice-Chair of the Research Committee for Pride Ortho.

References

  1. American Academy of Orthopaedic Surgeons. AAOS Commits $1 Million to Support Diversity Initiatives. Available at: https://www.aaos.org/aaosnow/2022/jun/diversity/diversity01/. Accessed July 31, 2022.
  2. Davis CL. Inclusion is Puzzing. Available at: https://cherriedavis.com/inclusion-puzzle/. Accessed May 31, 2022.
  3. Brownlee D. The Dangers of Mistaking Diversity For Inclusion in the Workplace. Available at: https://www.forbes.com/sites/danabrownlee/2019/09/15/the-dangers-of-mistaking-diversity-for-inclusion-in-the-workplace/?sh=56385e9a4d86. Accessed July 31, 2022.
  4. Merriam-Webster. Ally. Available at: https://www.merriam-webster.com/dictionary/ally. Accessed July 31, 2022.
  5. Melaku TM, Beeman A, Smith DG, et al. Be a better ally. Available at: https://hbr.org/2020/11/be-a-better-ally. Accessed May 31, 2022.
  6. Ellis D. Bound together: allyship in the art of medicine. Ann Surg. 2021;274:e187-e188.
  7. FitzGerald C, Hurst S. Implicit bias in healthcare professionals: a systematic review. BMC Med Ethics. 2017;18:19.
  8. Hoffman KM, Trawalter S, Axt JR, et al. Racial bias in pain assessment and treatment recommendations, and false beliefs about biological differences between blacks and whites. Proc Natl Acad Sci U S A. 2016;113:4296-4301.
  9. Meghani SH, Byun E, Gallagher RM. Time to take stock: a meta-analysis and systematic review of analgesic treatment disparities for pain in the United States. Pain Med. 2012;13:150–174.
  10. Sabin JA, Greenwald AG. The influence of implicit bias on treatment recommendations for 4 common pediatric conditions: pain, urinary tract infection, attention deficit hyperactivity disorder, and asthma. Am J Public Health. 2012;102:988-995.
  11. Project Implicit. Implicit Association Test. Available at: https://implicit.harvard.edu/implicit/takeatouchtestv2.html. Accessed July 31, 2022.
  12. Martinez S, Araj J, Reid S, et al. Allyship in residency: an introductory module on medical allyship for graduate medical trainees. MedEdPORTAL. 2021;17:11200.
  13. Sun M, Oliwa T, Peek ME, et al. Negative patient descriptors: documenting racial bias in the electronic health record. Health Affairs. 2022;41:203-211.
  14. Russell ST, Pollitt AM, Li G, et al. Chosen name use is linked to reduced depressive symptoms, suicidal ideation, and suicidal behavior among transgender youth. J Adolesc Health. 2018;63:503-505.
  15. Catlin K, McGraw S. Better Allies: Everyday Actions to Create Inclusive, Engaging Workplaces. Better Allies Press; 2019.